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Full text of "United States Navy Medical News Letter Vol. 44 No. 1, 3 July 1964"

JUL 6 1964 




Vol. 44 



Friday, 3 July 1964 



No. 1 



TABLE OF CONTENTS 



MEDICAL ABSTRACTS 

The Changing Status of Tinea 

Capitis 3 

The Management of Chronic Pain- 

The Anesthesiologists' Role ... .6 
Nutritional Disease and the Eye 

(Part II) 8 

The Prolonged Effect of Muscle 

Relaxant . • 13 

FROM THE NOTE BOOK 

Field Training Exercise - Camp 

Lejeune, North Carolina 15 

Worldwide Aeromedical Evacua- 
tion 16 

MSC Training Program Moves 

Ahead 17 

MISCELLANY 



A Letter of Congratulations to 
the Hospital Corps from the 
Surgeon General 

Spray Cans Can be Dangerous . . 

American Board Certifications. . 

New Course in Orthotics and 
Prosthetic s 

ATTN: Hospital Corpsmen - 

Data Needed for a New Book. 



.18 
.19 
.20 



.21 
.21 



DENTAL SECTION 

Navy Expands Dental Officer 

Teaching Program 22 

Policy on Sterilization 22 

Personnel and Professional 

Notes 26 

PREVENTIVE MEDICINE 

Tuberculosis Control Program. . .28 

Military Entomology Information 
Service 29 

Know Your World 30 

New Test for Diagnosing Sporo- 
trichosis 31 

Ultraviolet Closed Circuit TV 

Microscopy 32 

Jim son Weed Poisoning - 

Tennessee 32 

Medical Practitioners and Pre- 
ventive Medicine 34 

Measles 37 

RESERVE SECTION 

American Psychological Assn. . . . 38 
American Board Certifications 

of U.S. Naval Reserve 

Officers 38 

The Selected Reserve (Part II) . . . 39 

MADIGAN GENERAL HOSPITAL 
MEDICAL LIBRARY 
PROPERTY OE U. S. ARMY 



United States Navy 
I- * 

MEDICAL NEWS LETTER 



Vol. 44 Friday, 3 July 1964 No. 1 

Rear Admiral Edward C. Kenney MC USN 
Surgeon General 
Rear Admiral R. B. Brown MC USN 
Deputy Surgeon General 

Captain M. W. Arnold MC USN (Ret), Editor 
Contributing Editors 

Aviation Medicine Captain C. E. Wilbur MC USN 

Dental Section Captain C. A. Ostrom DC USN 

Occupational Medicine .CDR N. E. Rosenwinkel MC USN 

Preventive Medicine Captain J. W. Millar MC USN 

Radiation Medicine .CDR J. H. Schulte MC USN 

Reserve Section, .Captain K. W. Schenck MC USNR 

Submarine Medicine .CDR J. H. Schulte MC USN 



Policy 

The U. S. Navy Medical News Letter is basically an official Medical Depart- 
ment publication inviting the attention of officers of the Medical Department 
of the Regular Navy and Naval Reserve to timely up-to-date items of official 
and professional interest relative to medicine, dentistry, and allied sciences. 
The amount of information used is only that necessary to inform adequately 
officers of the Medical Department of the existence and source of such infor- 
mation. The items used are neither intended to be, nor are they, susceptible 
to use by any officer as a substitute for any item or article in its original 
form. All readers of the News Letter are urged to obtain the original of those 
items of particular interest to the individual. 

Change of Address 

Please forward changes of address for the News Letter to: Commanding Offi- 
cer, U. S. Naval Medical School, National "Naval Medical Center, Bethesda, 
Maryland 20014, giving full name, rank, corps, and old and new addresses. 



The issuance of this publication approved by the Secretary of the Navy on 
4 May 1964. 



U. S. Navy Medical News Letter, Vol. 44, No. 1 3 

The Cha nging Status of Tinea Capitis 

By E. Richard Harrell, Jr. , M D, Department of Dermatology, University 
of Michigan, Ann Arbor. University of Michigan Medical Center Journal* 
30(1): 21, January-February 1964. 

Few diseases have undergone the revolutionary change in therapy that has 
occurred with ringworm of the scalp (tinea capitis) since the advent of the 
antifungal antibiotic, griseofulvin. Cure of this type of fungus infection can now 
be accomplished by the simple oral administration of griseofulvin, whereas 
previously, extensive topical therapy and, at times, an epilating dose of x-ray 

1 ^ 

therapy were required to effect a cure. 1 "- > The vast reservoir of obvious cases 
of tinea capitis has been largely eradicated by the widespread use of griseo- 
fulvin. New fungi, causing different forms of tinea capites, are gradually 
appearing, and making it necessary at this time to reassess the problem of 
diagnosis and treatment. 

Diagnosis. The term tinea capitis implies infection with one of many 
dermatophytes or ringworm fungi of the genera Microsporum , Trichophyton , 
or Epidermophyton. Since the early 1900 's the fungus most often isolated from 
human scalp infection has been Microsporum audouini . This organism was 
apparently brought to the eastern seaports of the United States from England 
and has since spread through all the major population centers of this country 
by direct human transmission. M. audouini causes infection among siblings 
and also epidemics of scalp ringworm in school children. 

This organism first invades the hair follicles of the scalp and pro- 
duces a sheath of small spores which surrounds the involved hairs. These hairs 
become brittle and break off soon after their emergence from the follicular 
orifice. This produces what appears to be an area of true alopecia. Upon 
close examination, however, a fine stubble of broken hair can be seen which 
differentiates this problem from that of alopecia areata in which the hair un- 
dergoes complete effluvium. The area of involvement is usually devoid of 
inflammatory reaction. The spores produce an intense blue-greenfluorescence 
when viewed in a dark room under Wood's light illumination. For this reason, 
the Wood's light has come into widespread use in the identification of tinea 
capitis, and false reliance has come to be placed upon this examination. Far 
too few physicians appreciate that many other fungi capable of causing tinea 
capitis do not fluoresce under the Wood's lamp. 

During the past decade there has been a great increase in the number 
of cases of scalp infection caused by Tricophyton tonsurans . Infections caused 
by this fungus were rare in the midwestern United States prior to 1950, 
although there was a well known focus in the Southwest and in Mexico. It has 
since gained a strong foothold in the Midwest by direct man-to-man trans- 
mission from workers who migrated here from the endemic area to help in 
the harvesting of fruit and vegetable crops. Examination of a segment of the 
school population of Wayne County, Michigan, indicates that there is a 

* Formerly The University of Michigan Medical Bulletin. 



4 U. S. Navy Medical News Letter, Vol. 44, No, 1 

surprisingly high percentage of T. tonsurans infection present. T. tonsurans, 
unlike M. audouini , does not fluoresce under the Wood's light, for the spores 
of this organism, instead of surrounding the hair with a sheath of spores, in- 
vade the hair shaft and are found in an endothrix position. Also, hair involved 
with this fungus is less likely to break off in a uniform fashion, and the in- 
fection is thus more subtle in its clinical characteristics. An inflammatory 
reaction, or kerion, is more apt to result from this type of hair infection than 
from M. audouini. Patients have also been seen with a scarring form of alo- 
pecia reminiscent of the cutaneous form of lupus erythematosus. Because of 
the varied clinical nature of such infections and a lack of Wood's light fluores- 
cence, microscopic examination of infected hairs is essential. 

Other ringworm fungi which invade the human scalp hair follicle are 
usually acquired by animal, rather than by human, contact. These infections 
are also nonfluorescent when examined under Wood's light with the exception 
of those caused by Microsporum canis. This organism, as well as Trichophy- 
ton mentagrophyte s and Trichophyton verrucosum , commonly produces apro- 
found inflammatory response which is granulomatous in nature. This reaction 
represents the host's effort to expel the infected hair, and, as such, is adesir- 
able phenomenon. However, the kerion reaction may be so intense that the 
entire hair follicle is permanently destroyed, thus producing an area of per- 
manent alopecia. If this appears likely, vigorous therapeutic steps should be 
taken to reduce the inflammation. 

Therapy . Noninflammatory Tinea Capitis . Prior to the advent of griseo- 
fulvin, the central problem in the treatment of noninflammatory tinea capitis 
was the unavailability of fungicidal or fungistatic medications which could be 
forced into the depth of the infected hair follicle. Ectothrix spores outside the 
follicular orifice could be eliminated by topical measures, but the base of the 
hair remained infected. Those fungi that produce endothrix infection were 
almost totally resistant to topical measures. T. tonsurans infections were 
considered virtually incurable by any method short of x-ray epilation, and 
even following this procedure there was a high rate of recurrence. 

Griseofulvin has now almost completely replaced older methods of 
treating noninflammatory tinea capitis. Such an infection is now simply managed 
by the oral administration of 2 50 mg of griseofulvin per day for six consecutive 
weeks. No topical (ointment) medication is necessary. Griseofulvin should be 
administered with or following a meal containing fat, since its removal from 
the gastrointestinal tract is intimately connected with fat absorption. Ignorance 
of this fact helps to explain some of the recorded instances of griseofulvin- 
resistant tinea capitis. The drug is exceedingly well tolerated and has a low 
incidence of sensitivity reactions even though it is derived from species of 
Penicillium . There is no cross sensitivity with penicillin. If daily adminis- 
tration of the drug is impractical, as in the treatment of a large number of 
children in an institution, then a large "one shot" dose can be used. Two grams 
of griseofulvin given in a single dose in such a situation will produce cure in a 
high percentage of the children. Any failure resulting from such a single treat- 
ment can be individually retreated with the long term dosage method. 






U.S. Navy Medical News Letter, Vol. 44, No. 1 5 

Inflammatory Tinea Capitis . The most common error made in the 
treatment of angry -appearing, inflammatory fungus infections of the scalp 
is the use of vigorous topical therapy. Indeed, no form of topical antifungal 
therapy is indicated in the treatment of a kerion reaction! The already in- 
flamed skin and subcutaneous tissue cannot withstand further insult by 
strong chemical agents without producing even greater inflammation. Manual 
epilation of infected hairs is the most important step in management. These 
hairs are invariably resting in a purulent pocket and can be painlessly re- 
moved with forceps. This procedure should be carried out daily until all the 
involved hairs have heen removed. Wet compresses of normal saline solution 
help to reduce the inflammation. If there is evidence of secondary bacterial 
infection, systemic as well as topical antibiotics should be administered. The 
inflammatory reaction may also be reduced with topical corticosteroids in a 
cream or lotion combined with a topical antibiotic. Occasionally a patient's 
reaction may be so severe that permanent hair loss would result from scar- 
ring unless a short "burst" of oral corticosteroids is given (for example 10 
to 20 mg of prednisone per day for a period of 3 to 4 days). The administra- 
tion of griseofulvin is probably unnecessary in the management of inflamma- 
tory forms of tinea capitis, since the response to the infection itself assures 
that the disease is self-limited and self-healing. 



References 

Gentles, J. C. : Experimental Ringworm in Guinea Pigs: Oral Treatment 
with Griseofulvin. Nature 182: 476, 1958. 

Williams, D. I. ; Martin, R. H. ; and Sarkany, I. : Oral Treatment of Ring- 
worm with Griseofulvin. Lancet 2: 1212, 1958. 

Arnold, H. L. , Jr. : Oral Treatment of Ringworm with Griseofulvin, Pre- 
liminary Report. Straub Clinic Proc. , Honolulu 25: 53, 1959. 
Miedler, L. J. ; Bocobo, F. C. ; and Eadie, G. A. : Tricophyton Tonsurans 
Infection of the Scalp, a New Menace. J. Michigan M. Soc 59: 1851, I960. 

$ & $ $ & $ 



In 1913 there were only 23,000 physicians in Russia. In 1961, the USSR had 
some 420, 000 physicians to meet the needs of a population of 220 million. At 
present, about 30, 000 new doctors graduate every year, but more are needed 
to keep up with net annual population increase of 3. 6 million and changes in 
the pattern of medical care. Facilities for undergraduate medical education 
in the USSR are accordingly being expanded. 

-WHO Chronicle 18(5): 154, May 1964. 



jjj >|s :'{. i\< s[c >[c 



6 U.S. Navy Medical News Letter, Vol. 44, No. 1 

The Management of Chronic Pa in. - 
The Anesthesiologists' Role 

By LT Homer L. Dixon MC USN*. From the Proceedings of the Monthly 
Staff Conferences of the U. S. Naval Hospital, NNMC, Bethesda, Md. 1963- 
1964. 

The Nature of Pain . Pain has two sites of origin: central pain, such as the 
painful aura of epileptiform seizures and conversion pain of hysteria {these 
are both rare forms of pain), and peripheral pain, the much more common 
and what the author will be concerned with in this article. The perception of 
peripheral pain is a very simple receptive and conductive mechanism from 
somatic and visceral nerve endings, but the reaction to the pain once it reaches 
the central stimuli areas is very complex, which is altered in the same person 
at different times, depending on the person and his environment at the time 
he experiences the pain. Thus, in the reaction to pain the most important as- 
pect is an awareness by the patient that the pain itself exists. 

The Role of the Anesthesiologist . By far the most common role the 
anesthesiologist plays in chronic pain management is to provide special tech- 
nical aid by performing diagnostic, prognostic and therapeutic blocks. Oc- 
casionally, however, the anesthesiologist will be responsible, as the physician 
of the patient, for the overall management of the patient and the problem. The 
special technical aid of diagnostic and therapeutic blocks is often best 
handled by the anesthesiologist, since inhis surgical anesthesia practice, he 
should have exceptional skill and dexterity with nerve block procedures. Al- 
though this does not guarantee him equally good success in pain problems.it 
at least is a great help to him. His everyday use of analgesics and sedatives 
makes him more acutely aware of the limitations, disadvantages and compli- 
cations resulting from their use. In daily practice the anesthesiologist sees 
and cares for patients who fear pain and consequently, he is one of many 
sympathetic and understanding people to whom the patient can look for sympathy 
and understanding of their pain problem. The agents used in management of 
chronic pain are two types: 1. Local anesthetics, e. g. , procaine, xylocaine, 
pontocaine, carbocaine, all are examples of these agents. Their individual 
properties such as fast onset and great penetration of xylocaine and carbocaine; 
the poor penetration and short duration of procaine; and the poor penetration, 
slow onset, but long duration of pontocaine are what determine which agents 
will be used. These agents are used as mentioned for diagnosis, prognosis of 
later surgery, and rarely as prophylaxis as in impending dystrophy. 2. Neuro- 
lytic agents, such as phenol and alcohol, which are only rarely used to control 
severe intractable pain in patients when neurosurgical interruption is not 
feasible, or in patients who refuse operation. 

Pain Syndromes . The first class is the group of neuralgias, such as 
trigeminal neuralgia. Local anesthetics are used for diagnosis, prognosis, 
* Staff Member of the Anesthesiology Service, USNH, Bethesda, Md. 



U.S. Navy Medical News Letter, Vol. 44, No. 1 7 

and to let the patient know how they will feel once the nerve has been sectioned 
by surgery. For occipital neuralgia, the same role is used for diagnosis and 
prognosis. However, in segmental neuralgias, such as severe herpes zoster, 
occasionally intermittent blocks of local anesthetics or continuous peridural 
anesthetics may be of benefit to get the patient through the severe acute stages 
of this disease, thus being used as therapy. In intractable radiculalgias, di- 
agnosis and prognosis should be the role for the anesthesiologist in performing 
blocks on these nerves. 

The second class of pain syndromes, the causalgias, are divided into 
two groups: 1. The major causalgias in the first group, which occur when 
there is incomplete severance of a large nerve, such as the sciatic or femo- 
ral nerve of the leg. This is actually much more common in military medi- 
cine where severe injuries are more frequently found. This is an area where 
anesthesiologists can be of great value. These people experience, acute, se- 
vere burning pain in the area, with hyperalgesia, vaso-motor disturbances, 
vasal spasm, and coolness of the area. Continuous or intermittent sympathetic 
blocks of these areas offer great relief and are thereby a therapeutic measure 
as well as a diagnostic and a prognostic procedure. If done in the acute stage; 
that is, before secondary hyper-sympathetic activity changes could occur with- 
in two or three days. Z. Minor causalgias, in the second group, are those that 
may occur in shoulder-hand syndrome with only mild irritation of various 
nerves. And for this group, sympathetic blockades, usually intermittent, are 
of good diagnostic, prognostic, and therapeutic value. In the amputation stump- 
pain syndrome, repeated local injections will only occasionally relieve the 
patient for any period of time; and, by far, the best treatment of choice is 
cordotomy. For such things as tendonitis and bursitis, every physician is 
aware of the hydrocortisone and local anesthetic injection used and most physi- 
cians have done this. This can often be of great value in the relief of pain of 
a fairly permanent duration. 

The malignant growth pain, either from direct extension or metastatic 
spread, is poorly treated with any local anesthetics or neurolytic agents. It is 
for diagnosis and prognosis only. All palliative procedures, such as bypass 
operations in gastrointestinal tract neoplasms, radiation therapy, castration, 
endocrine therapy, nitrogen mustard therapy, radioactive materials, bilateral 
adrenalectomy which will temporarily relieve this pain must be tried before 
any agents such as narcotics, nerve blocks, and/or surgery are tried. Then, 
only if the patient is in such poor condition that surgery is not feasible, or if 
the patient will not agree to surgery, should any attempt at blocking of these 
nerves be tried. 

In a peripheral vascular disorder, continuous sympathectomy with local 
anesthetics in the very early stages, before thrombosis can develop in the col- 
lateral circulation, is a definite benefit. This should be done within the first 
few hours and is of little or no benefit after a day has passed. If done early, 
this procedure will relieve the hyper sympathetic activity resulting in vaso- 
spasm and will thus keep the collateral vessel open, preventing it from be- 
coming hypoxic and thrombotic. Only in chronic vascular diseases such as 



8 U.S. Navy Medical News Letter, Vol. 44, No. 1 

Raynaud's disease, thromboangiitis obliterans and arteriosclerosis obliterans, 
can diagnosis and prognosis be done well with chemical sympathectomy by the 
anesthesiology department. Needless to say, no treatment is of a long-lasting 
value, but complete surgical sympathectomy is the optimal choice at the mo- 
ment. 

In visceral disorders, particularly of the head and neck, sympathetic 
blockade is rarely of any benefit for such things as cerebral vascular acci- 
dents. In patients who have residual effects from their cerebral vascular ac- 
cidents, it is extremely doubtful if any benefit can be expected, except on a 
psychotherapeutic level. With methods available now for anesthesia manage- 
ment during surgery, the patients with severe intractable angina pectoris are 
best treated by surgical methods with interruption of the sympathetic chain in 
the thoracic area. In extremely critical patients, in whom there is severe 
cardiac decompensation or other problems which make surgery impossible, 
continuous sympathectomy, peridural block, or less likely alcohol block of 
the paravertebral sympathetic chain, may be useful. One area where anes- 
thesiologists can be of considerable benefit is in the care of the patient with 
acute pancreatitis. This is again within the first day. Continuous peridural 
block with dilute solutions of local anesthetics will relieve the pain, vasospasm 
and resulting hypoxia of the pancreatic tissue and thus will assist the patient 
recovering from the attack. 

In summary then, the author feels that the anesthesiologist does have 
a definite role in the management of pain problems. Certainly in the diagnosis 
and prognosis of nearly all pain syndromes, they can be of great value to the 
physicians as well as to the patient, and in many acute pain problems such as 
the author has mentioned, anesthesiologists can employ procedures of great 
therapeutic benefit to the patient. Whereas, in chronic pain syndromes, surgi- 
cal interruption of the nerve fibers involved is nearly always the treatment of 
choice in the modern practice of surgery and anesthesiology. 

$ Jge $ $ $ $ 

Nutritional Disease and The Eye * 

By Donald S. McLaren MD, PhD, Borden's "Review of Nutrition Re- 
search, " 25(1): 1-11, January -March 1964. 

The B Complex Vitamins 
Anterior segment of the Eye 

Animal Experiments . In the experimental animal a variety of ocular lesions 
has been induced by isolated deficiency of most members of this group of vita- 
mins. "Spectacle eye, l! consisting of loss of fur of the eyelids in the rat and 
rabbit is especially associated with pyridoxine deficiency, incrustation of the 
lids with a dark red secretion of porphyrin from the Harderian gland inside 
the orbit is seen in deficiency of pantothenic acid, riboflavin, niacin, biotin, 
and vitamin B|2- Deficiency of riboflavin, pantothenic acid, pyridoxine, niacin, 

* Concluded from the Medical News Letter, Vol. 43, No. 12, 19 June 1964. 



U. S. Navy Medical News Letter, Vol. 44, No. 1 9 

and biotin have all been shown to produce vascularization and other changes 
in the cornea. The first experimental cataract produced by nutritional defi- 
ciency was in rats deficient in vitamins of the B complex. Subsequently other 
workers observed lens opacities in varying proportion of rats, and several 
other species deficient in riboflavin. Deficiency of several vitamins of the B 
complex in the diet fed to the mother rat during the gestatory period has caused 
congenital eye malformations in the young. Those known to cause ocular defects 
are riboflavin, folic acid, pantothenic acid, niacin, and vitamin ~B\z- 

Disease in Man. Human nutritional deficiency disease is rarely, if 
ever, a manifestation of lack of a single nutrient. This is especially true of 
vitamins of the B complex which are usually found together in nature. Vascu- 
larization of the cornea in man and certain other ocular signs were first re- 
ported to respond to riboflavin in studies carried out in the southern United 
States. Subsequently many other workers reported a high incidence of circum- 
corneal injection and corneal vascularization in groups receiving a reasonably 
adequate dietary. It is now evident that this was due to misunderstanding of 
the normal variations in the vascular pattern of the limbic plexus. True vas- 
cularization of the cornea is an infrequent manifestation of hyporiboflavinosis 
in man. 

A superficial keratitis in malnourished individuals, to which the name 
"corneal epithelial dystrophy" was given, has also been attributed to deficiency 
of B vitamins, especially riboflavin. It is doubtful, however, if this is a sep- 
arate entity from epidemic keratoconjunctivitis of viral etiology. Similarly, 
claims that corneal lesions occur in pellagra, and that angular blepharocon- 
junctivitis responds to pyridoxine, require substantiation. An interesting syn- 
drome, known as "shibi-gatchaki" in the area of Japan where it has been re- 
ported, includes lesions of the skin and mucous membranes suggesting pellagra 
and hyporiboflavinosis, as well as dim vision, photophobia and superficial dif- 
fuse keratitis. 

Posterior segment of the Eye 

Animal Experiments. Japanese investigators have reported various retinal 
lesions in deficiency of riboflavin, niacin, pantothenic acid, pyridoxine, and 
vitamin ~B\2- Damage to the optic pathways, resembling the changes in human 
nutritional amblyopia, has been produced by chronic thiamine deficiency and 
by combined deficiencies of thiamine and riboflavin in the rat. Finally, hemor- 
rhagic lesions in parts of the midbrain have been reported in thiamine -deficient 
rats, pigeons, and monkeys. These changes closely resemble those found in 
Wernicke's encephalopathy. 

Disease in Man. Nutritional amblyopia (nutritional retrobulbar neuro- 
pathy) as well as other conditions, such as Wernicke's encephalopathy and 
fundus changes, have been noted in man. 

In nutritional amblyopia the symptomatology is characterized by blur- 
ring of vision for both near and distant objects, frequently accompanied by 
photophobia and retrobulbar pain. Visual field examination reveals central or 



10 U. S. Navy Medical News Letter, Vol. 44, No. 1 

centrocecal scotomata with little or no peripheral contraction. Unlike the toxic 
amblyopias the area of field involved is confined to that served by the papillo- 
macular bundle and post-mortem studies confirm this. Many hundreds of cases 
occurred in the Far Eastern prisoner-of-war camps in World War II, leaving 
varying degrees of visual disability short of complete blindness. Under these 
conditions of special privation and also in several endemic foci, the damage 
to the optic nerve was but part of a generalized neuropathy. The precise etiol- 
ogy is still not clear, although most investigators are agreed on the role of 
dietary deficiency, especially of the B vitamins. The evidence for an associa- 
tion with beriberi has been challenged. Some cases have appeared to respond 
well to riboflavin, and others to vitamin Bj^- 

Wernicke's encephalopathy, due to acute thiamine deficiency, also oc- 
curred under prison camp conditions. It is also seen in the terminal stages of 
chronic alcoholism. Nystagmus, an oscillatory movement of the eyeballs, is 
invariably present and is of considerable diagnostic value as it is the earliest 
sign to develop. Other ocular features include external rectus fatigue and pa- 
ralysis, complete disconjugate wandering, loss of visual acuity and papill- 
edema. A similar syndrome responding dramatically to niacin has been des- 
cribed. 

Fundus changes have been reported in infantile beriberi, and there is 
evidence of impairment of dark adaptation responding to riboflavin. Conflicting 
reports have been made concerning an association between disturbance of vita- 
min B.-, metabolism and the development of retinopathy in diabetes. Wide- 
spread retinal hemorrhages have been described in megaloblastic anemias of 
nutritional origin. 

Other Nutrients 

Vitamin C. The healing of corneal wounds is delayed in animals, and intra- 
orbital hemorrhage is quite frequent in human scurvy. Despite the high con- 
centration of ascorbic acid in the normal lens, cataract is not a feature of 
scurvy nor do large doses of this vitamin retard the progression of opacifica- 
tion of the lens. 

Vitamin D and Calcium. The hypoglycemia of tetany, experimentally 
in animals and in man, frequently results in zonular cataract. There is no 
direct association of this lesion with rickets. Vitamin D poisoning, and other 
causes of hypercalcemia also can cause deposition of calcium in many tissues, 
including the conjunctiva and cornea. 

Vitamin E. Deficiency may produce congenital malformations of the 
eye in animals but is not known to be harmful to the eye in man. 

Vitamin K. Hemorrhage into the retina in the newborn infant appears 
to be related, at least in some cases, to a vitamin K deficiency in the mother 
and prenatal therapy is reported to lower the incidence of the condition. 

Zinc. This trace element is in relatively high concentrations in the 
pigmented parts of the eye. It is part of the enzyme, alcohol dehydrogenase, 
probably identical to retinene reductase. This may explain the defect in dark 



U.S. Navy Medical News Letter, Vol. 44, No. 1 11 

adaptation reported in some patients with zinc deficiency secondary to liver 
disease. 

Proteins and Amino Acids. Animal experiments have revealed a re- 
ma rkable~dTgrTe~^f*Te~sTsTancToTthe eye to harmful effects on growth, similar 
to that described earlier in general inanition. Prolonged protein deficiency 
has produced cataract in pigs and various ocular malformations in young rats 
resulting from maternal deprivation. Corneal vascularization has been pro- 
duced in the rat by a deficiency of each of the essential amino acids and of 
protein. Lens opacities have been reported in rats deficient in certain amino 
acids, most notably tryptophane. 

The ocular lesions found frequently in human protein malnutrition 
(kwashiorkor) are due to an accompanying deficiency of vitamin A. Protein 
deficiency may sometimes be indirectly involved by affecting the metabolism 
of vitamin A. 

Carbohydrates. High concentrations of D-galactose, D-xylose, and 
L-arabinose result in cataracts in rats. Of metabolic, rather than dietary, 
origin is the cataract developing in diabetic animals and humans and in the 
disease galactosemia. 

Lipids. Arcus of the cornea is a feature of the hypercholesterolemic 
state in rabbits. Arcus senilis in man also bears a relationship to raised serum 
cholesterol and phospholipids. Xanthelasma, the deposition of cholesterol in 
the peri-global tissues, is frequently associated with hypercholesterolemia 
and coronary heart disease. The presence of bright orange -colored plaques, 
possibly of cholesterol, at the bifurcation of retinal arterioles in about 10% 
of patients with occlusive disease within the carotid and vertebral -basilar 
arterial systems recently has been reported. They are indications of general- 
ized atherosclerosis in which dietary fat may play some etiologic role. 

Ingested Toxins 

The ocular manifestations of toxic doses of vitamins A and D have been de- 
scribed. There now is good evidence for believing that amblyopia occurring in 
chronic alcoholics, and especially liable to develop if this is combined with 
excessive smoking (tobacco-alcohol amblyopia), is a secondary form of nu- 
tritional amblyopia^ The pathology is identical and good results have been ob- 
tained with thiamine and more recently with vitamin B^ therapy. 

Contamination of cooking oil with argemone oil from a member of the 
poppy family has been shown to be responsible for outbreaks of epidemic drop- 
sy among some Indian communities. Glaucoma has long been reported to be 
a feature of this condition but recent work casts doubt upon this. 

Cataract. There is considerable evidence that senile cataract has a higher in- 
cidence and earlier age of onset among the peoples of Asia and Africa than in 
North America and Europe. In the experimental animal, deficiency of ribo- 
flavin, certain amino acids and protein have been shown to cause cataract. 



12 U.S. Navy Medical News Letter, Vol. 44, No. 1 

Opacification of the lens is a long-time process. By the time visual acuity is 
impaired, irreversible changes have taken place. It is not surprising then that 
vitamin therapy applied at this stage has proved ineffective. It is possible that 
the cataract described in young malnourished adults in Indonesia is of nutri- 
tional origin. 

Discrete Colliquative Keratopathy . Discrete colliquative keratopathy was 
applied by the writer to a mysterious disease of the cornea, first described 
in malnourished Bantu children in South Africa. The strictly localized area of 
corneal softening in an otherwise normal eye is difficult to explain. It is quite 
distinct from the generalized keratinization and softening of keratomalacia, 
with which it has been confused. This eye condition has been reported only 
among the Bantu peoples of Africa; it is unknown in other parts of the world 
where childhood malnutrition is rife. 

Malnutrition and Trachoma . While it is true that trachoma is common 
among malnourished communities there is no proof that this is due to poor diet 
rather than to poor hygiene. The consensus of clinical opinion is that the cor- 
neal complications of trachoma progress more rapidly in the malnourished 
rather than the well-nourished subject but also cachectic children seem to be 
particularly immune to contracting infection. It may be that their conjunctivae 
lack certain enzyme systems essential for the virus. 

Refractive errors . The refractive state of the eye appears to be very 
largely under genetic control. Whether environmental factors can influence 
refraction is not known, circumstantial evidence that they may do so is accu- 
mulating. A high incidence of myopia has been reported from a famine area 
in Tanganyika, although the refraction of similar tribes in other parts of the 
country is normal. Both premature infants and marasmic infants are more 
myopic than normal controls. After infants recover from the marasmus their 
eye refraction returns to normal, indicating a temporary disturbance in ocular 
dynamics rather than an effect on the growth of the eye. 

It has been claimed that school children with advancing myopia eat less 
first class protein than those with no deterioration in their refraction and that 
the progress of myopia can be halted by dietary means. 

Vitamin A deficiency is prevalent throughout Asia and parts of Africa 
and Latin America. In the most susceptible age group, the pre -school child, 
this dietary deficiency accounts for the major proportion of blindness and 
makes a considerable contribution to the high mortality. Evidence is presented 
of a re-awakening concern about this grave, essentially preventable, nutritional 
eye disease. The dangers of vitamin A toxicity are also pointed out. 

Nutritional amblyopia, tobacco-alcohol amblyopia, certain encephalop- 
athies and some diseases affecting the cornea are due to deficiency of B vi- 
tamins. All these conditions are of considerable importance in certain endemic 
foci and under conditions of special privation. Deficiency or excess of many 
other nutrients are known to produce ocular lesions under experimental condi- 
tions. Some, for example excess lipids and protein deficiency, may have a 
role in human eye disease but exploration of all the implications has barely 
begun. 

$ :£ ;$: 4° $ $ 



U.S. Navy Medical News Letter, Vol. 44, No. 1 13 

Prolonged Effect of Muscle Relaxant 

By LCDR Robert C. Garrison MC USN*. From the Proceedings of the 
Monthly Staff Conferences of the U.S. Naval Hospital, NNMC, Bethesda, 
Md. 1963-1964. 

The application of various paralytic drugs in modern anesthesia has contri- 
buted greatly to increased patient safety by decreasing surgical time in pro- 
cedures where excess muscle tone would hinder the operation, and by virtually 
eliminating the need for deep anesthesia. However, as with many things, this 
boon has not been without its problems, chief among which is the potentiality 
for persistence of the neuromuscular block beyond the desired limit of surgi- 
cal relaxation. 

Case Report. The patient was a 39 -hour old female, brought to surgery for 
treatment of congenital bowel obstruction. Except for the failure to pass stools, 
she was presumed to be a normal infant, having good color, respiration, and 
activity, after an unremarkable labor and delivery. 

Anesthesia was begun and maintained in a standard fashion, using 
Halothane, nitrous oxide, and oxygen alone. Laparotomy revealed no specific 
obstructive lesion, with surgery consisting mainly of a visual check of the 
entire gut and lysis of flimsy adhesions in the cecal area. Because of moderate 
difficulty in replacing the bowel prior to closure, the standard reduced new- 
born dose of 0. 3 mgm/kg of d-tubo curarine was given intravenously. This 
produced no noticeable effect and was repeated after 20 minutes, again without 
result. At this point the usual pediatric dose of 2 mgm/kg of succinylcholine 
was given intravenously. Relaxation immediately ensued in atypical fashion, 
and abdominal closure was completed without further use of relaxants. 

The anesthetic agents were then discontinued and the usual maneuvers 
preparatory to removal of the endotracheal tube performed; but the child made 
no movement or effort to breathe whatsoever, despite stimulation by the suction 
catheter and deliberate mild hypoventilation to increase pC0 2 . 

From the injection of succinylcholine at 2230 until 2330 during which 
interval artificial ventilation with oxygen was performed, the child made no 
movements other than a curious half opening of the right eyelid with each force- 
able ventilation, and a rare ineffectual gasp. From 2330 to 0500, there was 
a progressive return to a pattern of respiratory effort, but essentially no tidal 
air was moved. After 0500 the volume of tidal air gradually increased until it 
was judged normal at 1040. At 1415 she was able to maintain her own airway 
and ventilate well with the endotracheal tube removed. 

When any patient is noted to be slow in regaining adequate respirations 
after anesthesia is discontinued, several possible causes exist and need to be 
differentiated. Most of these are due to some combination of the sudden loss 



* Staff Member of the Anesthesiology Service, USNH, Bethesda, Md. 



14 U.S. Navy Medical News Letter, Vol. 44, No. 1 

of painful stimuli, decreased carotid body activity with low pCC>2 and high 
pC>2, vagal stimulation from the endotracheal tube, and residual effect of de- 
pressant drugs. These can be evaluated and corrected rather quickly by stand- 
ard methods. When apnea or hypoventilation still persists, it is then presumed 
to be a persistent effect of any neuromuscular blocking drugs used. 

The common muscle relaxants used in anesthesia are of two types, 
based on their relationship to the action of acetylcholine. Succinylcholine and 
decamethonium depolarize the motor end plate in the same fashion as acetyl- 
choline (but of longer duration), and are called depolarizing blocking agents. 
Curare and curare -like drugs do not depolarize; and interfere on a mass -action 
basis with the depolarizing effect of acetylcholine, and are called non-depolarizing 
or competitive blocking agents. Because curare does act on a mass-action 
basis, anticholinesterase drugs such as edrophonium and neostigmine, by in- 
creasing the amount of acetylcholine left at the motor end plate, act as anti- 
dotes for prolonged effect of curare-type relaxants. Unfortunately, no such 
antagonists are yet available for succinylcholine. 

Because this patient had received curare, edrophonium and neostigmine 
were given to test for the possibility of its being a reversible problem, but 
with no effect. 

When depolarizing agents have been used over a long time during a 
procedure, there can be a gradual shift at the motor end plate from its de- 
polarized condition to a non-depolarized state, but still insensitive to acetyl- 
choline. The mechanism of this shift is as yet unexplained, but in such a case, 
anticholinesterases will then work to antagonize the paralysis. This was tried 
about three hours post-operatively, again with no result. 

With the continued persistence of paralysis, despite these maneuvers, 
and in view of the very small amount of succinylcholine used, it was felt to be 
on the basis of failure of the normal mechanism for removal of succinylcholine 
from the body. Usually a single injection will produce paralysis for only five 
minutes, due to the rapid hydrolysis by plasma cholinesterase (also called 
pseudocholinesterase) to choline and succinylmonocholine, a very weak re- 
laxant. When plasma cholinesterase activity is low, then succinylcholine is 
destroyed proportionately slowly. Cholinesterase activity is low in about 1 in 
1000 patients, frequently on the basis of liver damage or immaturity. In this 
child, where the normal esterase activity is 80 (micro-moles of acetylcholine 
hydrolyzed by 1 cc of serum in 30 minutes at 37°C), the measured level was 
only 13, and may have been less due to margin of error at the low end of the 
scale. It is not too surprising then that succinylcholine action in her was pro- 
longed 200 times the normal duration. 

In one out of five primary succinylcholine apneas, the esterase activity 
is measured as normal by the usual method. By using dibucaine or procaine 
as an inhibitor in the usual test, an atypical type of serum cholinesterase has 
been detected, which has only a weak ability to hydrolyze succinylcholine, and 
occuring on a familial basis, without relation to liver problems. When this 
type is detected, the entire family needs to be warned, about succinylcholine 
as well as local anesthetics, such as procaines and dibucaine which also de- 
pend on ester hydrolysis for destruction. 



U.S. Navy Medical News Letter, Vol. 44, No. 1 15 

Following return of normal respirations, this patienthad several brief 
episodes of apnea, apparently in relation to small amounts of neostigmine 
given for its muscarinic action on the bowel. It is quite possible that there 
was still a subclinical residual of succinylcholine action, which acted syner- 
gistically with the nicotinic action of this weak dose of neostigmine to produce 
a recurrence of paralysis. Subsequent doses of neostigmine were withheld, 
and the child had no further paralytic or respiratory problems. 

After seeming to recover well from her surgery, she was discharged 
from the hispital. Two days later, she developed a fulminating entero-colitis 
and died, apparently of endotoxin shock. Pathology did not report any findings 
that might suggest any other reasoning behind her apneic problem. 



From the Note Book 

Field Training Exercise 
Camp Lejeune, North Carolina 

Naval Hospital Surgical Team No. 

St. Albans 1 

Philadelphia 3 

Bethesda 5 

Portsmouth, Va. 12 

The four Surgical Teams listed above and fourteen Augmentation Personnel, 
from Naval Hospitals on the East Coast, participated in a Field Training Exer- 
cise during the period 3 May to 8 May at Camp Lejeune, North Carolina. CAPT 
H. G. Stoecklein MC USN, represented the Bureau of Medicine and Surgery 
and CAPT Howard Baker MC USN, participated as an observer. This exercise 
was planned at this time so as to coincide with the Special Purpose Exercise 
planned for the Secretary of the Navy, the Honorable Paul H. Nitze, Lt General 
Kim DuChan, Commandant of the Korean Marine Corps, General Wallace M. 
Greene, Jr. , Commandant of the U.S. Marine Corps, and the Armed Forces 
Staff College members. 

These mobile Surgical Teams, four of twenty, established by BuMed 
Instruction 6440. IB, are designed to expand the surgical capability of the 
operating forces of the Navy and Marine Corps under emergency conditions. 
They are also designed to provide surgical support and emergency treatment 
in disaster control measures within and outside the United States. The Aug- 
mentation Personnel, as designated by BuMed Instruction 6440.2, will serve 
to bring the medical units of the Fleet Marine Force up to combat strength 
and to insure that the medical officers assigned meet the specialist require- 
ments as set forth in the current U. S. Marine Corps Tables of Organization. 

This exercise familiarized all participants with the medical support 
requirements of the Fleet Marine Forces, and the capability of the Navy Medical 



16 U.S. Navy Medical News Letter, Vol. 44, No. 1 

Corps to furnish this support. In addition, it afforded them the opportunity 
to familiarize themselves with the field units, the Supply Blocks, field admin- 
istrative procedures and field evacuation systems. All members participated 
in dry net training, helicopter demonstrations, field stripping and firing of 
the 45 pistol, and treatment of casualties during daylight and under blackout 
conditions. All Surgical Team members and Augmentation Personnel were 
special guests for the Special Purpose Exercise conducted on 7 May. The high- 
lights of this exercise were the viewing of the static display of the Battalion 
Landing Team and its equipment, the assault on a fortified position by a rifle 
platoon, a close air support demonstration, and an amphibious landing at 
Onslow Beach byaBLT. The members found the day interesting and informa- 
tive and unanimously agreed that it provided them with a comprehensive view 
of the Marine Corps within a limited space of time. 

A special demonstration of a collecting and clearing company in action 
was presented for the benefit of the Secretary of the Navy, the Commandant 
of the Marine Corps, the Commanding General of the Second Marine Division, 
and other visiting dignitaries. Following this special presentation, the public 
(civilian and military) were invited to attend. The Surgical Teams from St. 
Albans and Bethesda, and Augmentation Personnel participated in the demon- 
stration. All observers were greatly impressed. General Greene, the Com- 
mandant of the Marine Corps, commented to CAPT Stoecklein that he was 
greatly impressed with what he saw, and wanted to know if this medical sup- 
port would be available to him on call. He was assured that surgical teams 
and augmentation personnel would be on station within a matter of hours. 

The enthusiasm, initiative, and ingenuity demonstrated by all partici- 
pants during this entire training period were outstanding and deserving of the 
highest praise. In the critique which followed the exercise, team Captains 
were advised to report back to their parent Commands and continue training 
on the local level. Surgical Team members were urged to open, inspect and 
familiarize themselves with the contents of the Surgical Team blocks. 

****** 
Worldwide Aeromedical Evacu ation 

The attention of Medical Department personnel is invited to the comprehensive 
joint regulation of the Air Force, Army, Navy, and Marine Corps -AFR 164-1, 
AR 40-535, OPNAVINST 4630. 9B and MCO P4630. 9 of 15 May 1964, bearing 
the above title. This regulation establishes operative and administrative res- 
ponsibilities and procedures for worldwide aeromedical evacuation. It imple- 
ments STANAG 3204, SOLOG 83.SEASTAG 3204, and IADB (Inter-American 
Defense Board) Resolution 46 by incorporating standardized aeromedical eva- 
cuation terminology and procedures which under terms of the above cited docu- 
ments are binding commitments of the U. S. Government. Requests for exception 
should be forwarded through appropriate channels of the Service concerned. 

****** 



U.S. Navy Medical News Letter, Vol. 44, No. 1 17 

MSC Training Program Moves Ahead 

The following MSC officers received degrees as indicated on 7 June 1964 from 
George Washington University, Washington, D. C. , at the Spring Convocation. 



Master's Degree 

LCDR R. V. L'ltalien 
LCDR J. C. Smout 
LT C. J. Pearce 
LT L. H. Webb 

Ba chelor's Degree 

LCDR D. Becker 
LCDR H. DeGrotte 
LCDR R. G. DeWitt 
LT F. G. Anderson 
LT L. E. Angelo 
LT A. Bender 
LT C. J. Dunham 
LT R. B. Kessler 
LT F. J. Redding 
LT W. H. Schroeder 
LT R. W. Tandy 



Duty Station 

NH, Phila, (Residency Hosp. Admin) 
PRNC, (DUINS, GWU) 
PRNC, (DUINS, GWU) 
NMS, Bethesda, Md. 



NMS, Bethesda, Md. 
NNMC, Bethesda, Md. 
NH, Bethesda, Md. 
NSHA, Bethesda (DUINS) 
PRNC, (DUINS, GWU) 
PRNC, (DUINS, GWU) 
NH, Annapolis, Md. 
NH, Quantico, Va. 
NSHA, Bethesda, (DUINS) 
NH, Bethesda, Md. 
NNMC, Bethesda, Md. 



As noted from the above, two officers received their degree upon completion 
of the course at the Naval School of Hospital Administration. This was possible 
due to their participation in the MSC training program on a part-time, off-duty 
basis prior to entering the class at NSHA in August 1963. Of equal importance, 
is the fact that many of the other officers continue their educational program 
on a part-time, off-duty basis since they graduated from NSHA. Such accomplish- 
ments will soon be recognizedby many other MSC officers who have graduated 
from the Naval School of Hospital Administration since its affiliation with the 
George Washington University on 5 August I960. Through this affiliation and 
the tremendous efforts put forth by MSC officers toward their educational pro- 
gram, the goal of obtaining a degree has been and will be attained. 

Opportunities are available for all MSC officers to pursue their aca- 
demic program under Navy sporsorhip as outlined in BuMed Instructions 
1520. 12B and 1500. 7A. Keen foresight, sufficient energy, and utilization of 
free time from military duties will provide the ambitious officer a sound pro- 
gram of self improvement that will assist him (1) to perform more efficiently; 
(2)to prepare himself for higher responsibilities;^) to increase his promotion 
potential ;(4) to maintain continuity in his academic program ;and( 5) to increase 
his employment opportunities after retirement. 

— Medical Service Corps Div. , BuMed. 



18 



U.S. Navy Medical News Letter, Vol. 44, No. 1 




MISCELLANY 



An Open Letter From Rear Admiral E. C. Kenney 
Surgeon General of the U. S. Navy to all Hospital 
Corpsmen Upon the Occasion of the 66th Anniversary 
of the Founding of the Hospital Corps 



On the 66th anniversary of the U. S. Navy Hospital Corps, I 
desire to extend once again my congratulations and best 
wishes to all the men and women members who comprise 
this Corps of the Navy Medical Department. 

The loyalty and devotion continuously displayed is that 
which has earned the Hospital Corps the respect and ad- 
miration of military and civilian personnel the world over. 
As I review the varied assignments required for Hospital 
Corps personnel I find, as in the past, a strong and dedi- 
cated support to the accomplishment of our mission. The 
many personal sacrifices and long hours of hard work dedi- 
cated to serve others whenever and wherever called upon 
serve as an individual tribute to each and every member. 

On behalf of the Navy Medical Department - WELL DONE. 



HAPPY BIRTHDAY 




E. C. KENNEY 



U.S. Navy Medical News Letter, Vol. 44, No. 1 19 

Spray Cans Can Be Dangerous 

From The Flame XVII{5): 10-11, April 1964. Monthly publication by 
Cabot Industries, O. L. Fitzrandolph-Editor, 125 High Street, Boston, 
Mass. 

Do you have an aerosol dispenser of any kind in your home? If you do, please 
take a few minutes to read the rest of this article; it may save you a lot of 

trouble. 

All types of products are put up in aerosol dispensers, from paints 
and varnishes to whipped creams. They include bug and animal repellents, 
hair sprays, cleaning fluids, shaving cream, toothpaste, deodorants, polishes, 
air fresheners, waxes, de-icers and ether car starters. You have at least one 
of these in your home and probably more. They are very handy and generally 
do a good job, but they can also be very dangerous. 

Here is the reason. When a product is put into the container, a "pro- 
pellant, " usually a liquefied gas, is sealed in with it. Some of the liquid gas 
instantly vaporizes, filling the space inside the cannot occupied by the product. 
This vaporized gas builds a pressure inside the container so that when the 
valve is opened (generally a button which is depressed), it forces the product 
out. As the product and some of the gas are dispersed by opening the valve, 
more gas evaporates inside the can, keeping up the pressure. 

Most home product aerosol spray cans are packed to generate 40 pounds 
pressure at 70° F. The cans are tested to stand pressures three to four times 
this amount. 

Under normal conditions these containers are not dangerous. But ex- 
treme heat may build up the pressures until the can explodes like a bomb. The 
big danger is in disposing of the container after the product is gone. There is 
always more propellant, or gas, put into the container than is needed to expel 
the product, so that there is adequate pressure in the can to get all of the 
product out. That means that there is generally some of the gas left when all 
the product is gone. 

In many cases, the supposedly empty can goes into the wastebasket 
and is eventually dumped in the incinerator. When the can hits the heat in the 
incinerator, the gas expands, bursting the can. The can may take off like a 
rocket or explode, spraying pieces of metal like shrapnel. There have been 
many cases of injury and sometimes death from this cause. 

Just to keep positivistic thinking that "they can't be really dangerous" 
in the proper prospective, the author quotes a few incidents. 

A woman in Willow Grove, Pennsylvania, tossed an empty bug-spray 
on a wastepaper fire and turned back toward her kitchen. There was a dull 
thud and a piece of the ragged metal struck her in the neck, severing the jug- 
ular vein. She was dead 15 minutes later. 

A youngster spraying his Christmas tree with liquid snow, heated the 
can in hot water to "pep-up" the propellant. He shook the can and lost an eye 
and part of his lower jaw. 



20 U.S. Navy Medical News Letter, Vol. 44, No. 1 

A fellow cleaning up his yard threw an abandoned can on his fire of 
burning leaves. It exploded and a piece severed an artery in his leg. He died 
before getting help. You can see the danger of mishandling these containers. 

Also, some of the products themselves are dangerous. Many contain 
oil or ingredients that are flammable and may catch fire from an open flame 
or hot surface, causing an explosion. Paints and lacquers, some oil-type 
sprays, even some hair sprays, are of this type. Some are toxic to breathe 
for any length of time and some are poisonous if they get into your mouth or 
on your skin. 

Most people do not take time to read instructions on things and this 
habit canbe their undoing. So, read all instructions on aerosol containers and 
heed them. 

Keep them away from excessive heat such as radiators or stoves. 
Be very careful where you spray and what you spray on. Never throw cans in 
wastebasket, incinerator or trash can without puncturing them. If possible, 
after the product has been used, bleed as much propellant from the container 
as you can by holding down the button. Do this in a well-ventilated area. 

Then, wrap the can-in newspaper and put it in the refrigerator over- 
night to cool. This lowers the pressure, if there is any. Next morning take 
the can, still wrapped in paper, turn bottom of can away from you and punc- 
ture with beer can opener. That's a lot of trouble, but at least it's safe. 

>'fi i'p *,< ?]« % ^ 

American Board Certificat ions 

American Board of Internal Medicine 

LCDR Vernon N. Houk MC USN 
LCDR Paul R. Minton MC USNR 
LCDR William M. Soybel MC USN 
LCDR Joe E. Whetsell MC USN 

American Board of Ot olaryngology 

LCDR Hugh O. deFries MC USN 

American Board of Pathology 

LCDR Robert A. Burke MC USN 
LCDR Robert I. Morgan MC USN 
LCDR Charles J. Stahl, III, MC USN 
LT Russell H. Clark, Jr., MC USNR 

American Board of Su rgery 

LCDR Ronald E. Goelzer MC USNR 



U.S. Navy Medical News Letter, Vol. 44, No. 1 21 

Instructio nal Course in Orthotics and Prosthetics 
for the Orthopedic Resident 

Location: U. S. Naval Hospital, Oakland, California 
Dates: 28 September 1964 through 1 October 1964 

This 4-day course has been established to familiarize the Orthopedic Resi- 
dent with the various orthotic and prosthetic appliances available to the 
patient; the fitting problems that occur due to specific peculiarities of each 
patient; the actual fitting of the patient; the evaluation of the completed devices; 
the method of correct and proper prescription ordering of appliances, and the 
basic construction methods of the more common orthotic and prosthetic ap- 
pliances. 

Requests should be forwarded in accordance with BUMED INST. 1520.8 
at least 4 weeks in advance of the convening date of the course. A limited 
number of eligible and interested officers may be provided with travel orders 
to attend at Navy expense. Others may be issued Authorization Orders by their 
Commanding Officers following confirmation by this Bureau. 

— Training Branch, Professional Div. , BUMED. 



N-O-T-I-C-E 



Personal Expe rience Stories of Hospital Corpsmen 
Desired for Inclusion in New Book 

Mrs. Eloise Engle of Falls Church, Virginia, is in the process of collecting 
reports of interesting personal experiences of hospital corpsmen for her new 
book "MEDIC. " The book will cover the work of enlisted medical department 
personnel of all the military services. She writes: 

"The problem is, as I see it, that corpsmen will not ordinarily come 
forward due to modesty or a feeling that someone else did something more out- 
standing. I need personal interviews (or reports) from corpsmen themselves 
who have been through World War II or the Korean Conflict, as well as import- 
ant peacetime events in the Army, Navy, Marine Corps, and Air Force. I need 
to obtain a first-hand picture of what problems were faced and how they were 
handled. Also, I am interested in other experiences such as space research in- 
volving corpsmen who volunteered for tests in full pressure suits and decom- 
pression chambers; tests in diving, underwater swimming, compression cham- 
bers and submarine service; experiments in acceleration and deceleration 
stresses, weightlessness, and g-forces; participation in environmental studies 
in the extremes of heat and cold; and fallout shelter habitability and depriva- 
tion tests. " 

Commanding Officers, Officers-in-Charge, Senior Medical Officers, 
and other cognizant officials are invited to submit recommendations as to who 
might be suitable and willing to be interviewed by Mrs. Engle. Such informa- 
tion should be addressed to her at 425 Crosswoods Drive, Falls Church, Va. 

— Editor 



22 



U.S. Navy Medical News Letter, Vol. 44, No. 1 



DENTAL 




SECTION 



Navy Expands Dental Officer Teaching Program 

The Dental Division of the Navy's Bureau of Medicine and Surgery has initiated 
a new program to augment the continuing education provided for naval dental 
officers. Specialists on the staff of the U.S. Naval Dental School, Bethesda, 
Maryland, will tour various large naval activities throughout the United States, 
presenting lectures and demonstrations for naval dental officers within each 

area. In this way, many dental officers 
who cannot attend the short postgraduate 
courses given at Bethesda will benefit 
from instruction by the school's staff 
in the latest developments in dentistry. 
Other Federal dental officers, as well 
as civilian dentists, will be invited to 
attend. RADM Frank M. Kyes, DC, 
USN, Assistant Chief, Bureau of Medi- 
cine and Surgery (Dentistry) and Chief 
of the Dental Division (seated) is shown 
discussing details of the tours with 
members of the first two teams. They are, from left: CAPT Peter F. Fedi, 
DC, USN, a specialist in periodontics; CAPT Frank J. Kratochvil, DC, USN, 
a prosthodontist specializing in removable partial dentures; and CAPT Angus 
W. Grant, DC, USN, whose specialty is oral roentgenology. Activities to be 
visited include U.S. Naval Training Center, Great Lakes, 111.; U.S. Naval 
Submarine Base, New London, Conn. ; U.S. Naval Base, Newport, R.I. ; U.S. 
Naval Air Stations at Pensacola and Jacksonville, Fla. ; Marine Corps Recruit 
Depot, Parris Island, S. C. ; U.S. Naval Station, Charleston, S. C. ; and Marine 
Corps Base, Camp Lejeune, N. C. The Bureau of Medicine and Surgery has 
authorized additional tours to be scheduled during the coming fiscal year. 




^ ;,': >]i ;'^ ;!< sj: 



Policy on Sterilization 

A recent tri-service study agreed that sterilization by boiling had been proven 
inadequate in destroying certain organisms and therefore was not profession- 
ally acceptable to the military medical services. Thus, surgical instrument 
sterilizers of the boiling water type, with the exception of a few for special 



U. S. Navy Medical News Letter, Vol. 44, No. 1 23 

application, have been deleted from the Federal Supply Catalog. This action 
is consonant with the information contained in Accepted Dental Remedies, 1964, 
which all Dental Officers are advised to consult for details. For the purpose 
of U. S. Navy Dental Corps policy then, sterilization is definedas the destruction 
of all microbial forms. This may be accomplished by steam under pressure 
(autoclave) or prolonged dry heat (oven). Disinfection is definedas destruction 
of infectious microorganisms only, and is not capable of destroying spores and 
certain resistant vegetative microbial forms. This may be accomplished by 
chemical agents (ethyl alcohol, quaternary ammonium compounds). 

The Autoclave. The most reliable sterilizing agent is superheated 
steam under pressure. No living thing can survive ten minutes direct exposure 
to saturated steam at 121°C (249. 8°F), which is attained under ideal conditions 
at sea level with 15 pounds pressure in the autoclave. However, additional 
time must be allowed for the items being sterilized to reach this temperature. 
Since it is the direct exposure to live steam (and not the pressure) which ster- 
ilizes, it is imperative that proper procedures be followed, e. g. , elimination 
of air pockets through proper pack preparation and loading, and elimination 
of air from the autoclave chamber. The latter is a frequently neglected step; 
it may be accomplished by flushing the autoclave with steam until the ther- 
mometer in the discharge line shows that the escaping vapor is at 100°C or 
higher, following which the sterilizing cycle is started. With a jacketedautoclave, 
sterilized material can be vacuum dried in a short time. 

The Oven. Recently made available in the Federal Supply Catalog under 
stocknumber 6530-962-9965, ( Sterilizer , Surgical Instrument , Dry HeatType, 
Electrically Heated, CRM, 111/2 x 61/2 x 5 inches, 110 volt, 60 cycle, AC, 
Unit: each. DMSC price $76. 00) is an excellent sterilizing oven which is 
especially appropriate for dental use. In the Defense Medical Materiel Board 
user test, the only disadvantage noted was the longer sterilizing time required, 
while this oven's greatest advantage was its ability to sterilize metal instru- 
ments on which it is essential to preserve cutting edges and where rust or 
tarnish is a factor. Its other reported advantages were no water level to 
maintain, thermostat adjustment easily made without opening the chamber, no 
pressure involved, very little heat dissipated from the sterilizer to the oper- 
ating room, instruments and packs ready for immediate use after the steriliz- 
ing cycle, and no dulling or temper change of cutting instruments and blades. 
As with the autoclave, the operator must allow time for the instruments to 
reach sterilizing temperature (160-180°C, 320-355°F) before timing the ster- 
ilizing cycle. Again, care should be given to proper loading of the chamber 
to permit adequate hot air circulation. 

Sanitization. All methods of sterilization and disinfection are impeded 
by the presence of debris. Numerous reports in the scientific literature il- 
lustrate the protective effect of organic debris against sterilization. Instru- 
ments must be scrubbed with brush, detergent and water, and subsequently 
rinsed before sterilizing. Syringe needles present a particular hazard in the 
difficulty of removing congealed blood from the lumen. Fre-sterilized disposable 



24 U.S. Navy Medical News Letter, Vol. 44, No. 1 

single-use needles are recommended. When it is necessary to reuse needles, 
they should be cleansed by passing a wire stylet through the lumen and rinsing. 
Considering the poor convection of autoclave steam through the narrow lumen, 
the dry-heat oven is the method of choice for sterilizing needles for reuse. 

Handpiece Sterilization . Conventional handpiece's may be sterilized 
either in the autoclave or the dry-heat oven. At the present time, there is no 
uniform method for sterilizing air-turbine handpieces. 

Charbeneau, G.T. &Berry, G. C. , JADA 59:732-737, 1959, described 
a simple and effective autoclave method for all metal dental instruments in- 
cluding the conventional handpiece. To prevent rusting, the instruments are 
coated before each autoclaving with a protective oil -water emulsion. Injection 
syringes and needles should not be coated with emulsion because of danger of 
oil emboli when used for injection. 

Modern silicone lubricants make oven sterilization of conventional 
handpieces appear feasible. The few literature reports on this subject are 
inconclusive. Further research and testing will be required before a firm 
policy can be established. There is no question that the oven will sterilize 
handpieces; the questions are on the adequacy of silicone lubrication in pro- 
longed use, and the unproven safety from topical toxicity. The two silicone 
products which have been recommended as substitutes for petroleum lubri- 
cants of required viscosities are: 

Type of Petroleum Silicone lubricant. (From FSC Group 91, 

lubricant Fuels, Lubricants, Oils, and Waxes.) 

Light machine oil 50 Centistoke "Damping Fluid" 

FSN 9150-664-0047 - 1 lb. can 



Petrolatum (grease) Grease, aircraft and instrument 

FSN 9150-272-3370 - 2 ounce tube. 



The "damping fluid" listed above is of the Dow Corning 200 series, 
whose freedom from topical toxicity has been well established. (Crowe, F.W. , 
JAMA 149:1464, 1952.) (Barondes, R. et al, J Mil Surg 106:378, 1950. ) The 
aircraft and instrument grease listed above is a mixture of Dow Corning 200 
series silicone fluid jelled with lithium stearate soap. Although there are no 
known published reports of toxicity tests, this grease has been widely used 
for years and no dermatitis has been reported. On these premises, the above 
described silicone lubricants are probably acceptable for handpiece lubrica- 
tion associated with oven sterilization. 

When oven sterilization is adopted as standard procedure, the hand- 
piece is sterilized after each patient. The following cleansing routine is rec- 
ommended. Each time water has entered the handpiece, or in any case, after 
it has been used six times, the handpiece is completely dismantled, thorough- 
ly cleansed with a solvent, dried, relubricated with silicones, wiped with a 
clean cloth to remove excess lubricant, reassembled and oven sterilized for 
11/2 hours at 175 C. This prolonged heating period is dictated by the metal 



U.S. Navy Medical News Letter, Vol. 44, No. 1 25 

mass of handpieces. After cooling, it is ready for use. Acceptable solvents 
for the two silicones described above are: amy! acetate, benzene, ethyl ether, 
gasoline, kerosene, methylene chloride, naphtha or toluene. 

Concerning air-turbine handpieces, there is no single sterilizing or 
germicidal method applicable to all models. Therefore, the dental officer 
should adopt the most effective procedure within the manufacturer 's directions. 
For those air-turbine handpieces which will tolerate it, the autoclave or oven 
should be used. For others, it will be necessary to use the germicidal oils, 
etc. recommended by the manufacturer, and to wipe the external surfaces with 
ethyl alcohol soaked sponges - -after each use and again before use on a new 
patient. 

The use to which a handpiece is to be put should be considered in 
relation to sterilization requirements. Oral Surgery requires a sterile hand- 
piece. The needs of clinical operative dentistry often dictate use of disinfection 
procedures. The Naval Dental School's Oral Surgery Department has success- 
fully used autoclaved Densco air-turbine handpieces for over a year with no 
evident damage to the instrument. After each use, the handpiece is completely 
dissembled, cleansed, lubricated with petroleum lubricants, aluminum foil 
wrapped (loosely to permit steam circulation), autoclaved and vacuum dried. 
Obviously this procedure is justified in cases where tissue may be deeply in- 
vaded. Alternatively, in clinical operative and prosthetic procedures wherein 
the handpiece is used almost constantly, some air-turbine models would be 
likely to break down as a result of frequent autoclave sterilization; and since 
tissues are not deeply invaded, chemical disinfection should suffice. 

Ethylene oxide sterilization offers much promise toward handpiece 
sterilization (Wachtel, L. W. & Armstrong, L. M. USN Med. News Letter 
43(4): 22, Feb. 21, 1964). Unfortunately, this system will require more re- 
search, development, test and evaluation before an ethylene oxide sterilizer 
can be standardized for fleet and field use. 

Disinfection . Chemical disinfectants have a distinct place in dental 
practice. As a whole, they are incapable of killing spore formers and the 
more resistant vegetative pathogens such as the tubercle bacillus and the 
hepatitis viruses. The Council on Dental Therapeutics of the American Dental 
Association recognizedthese and other limitations. It stipulates that chemical 
disinfectants must be effective in killing vegetative pathogens with the possible 
exception of M. tuberculosis within five minutes to be acceptable for dental 
practice. However, the Council recommends a minimum exposure of 15to30 
minutes to provide a margin of safety. Chemical disinfectants have poor pen- 
etration of organic materials; they are not acceptable for penetration of hinged 
or deeply grooved instruments; they are not acceptable for use on instruments 
which are to enter tissue or contact the patient's bloodstream. 

Although a variety of chemical disinfectants are available, other than 
the special disinfectant oils for high speed handpieces, only two are recom- 
mended for Dental Corps use: 70 percent ethyl alcohol and quaternary ammonium 
compounds. In common practice, chemical germicides are used as holding 



26 U. S. Navy Medical News Letter, Vol. 44, No. 1 

solutions for sterilized articles. Such holding solutions may readily be con- 
taminated with pathogens through careless handling; if this is to be used, the 
container should be covered, and special sterile tongs should be provided. Far 
more preferably, sterilized articles should be stored dry in the container in 
which they were sterilized. 

It is well established that the effectiveness of chemical disinfectants 
is reduced by organic contamination and dilution. Quaternary ammonium com- 
pounds degrade with age. A fresh supply should be provided at least once a 
day; none should be held overnight. 

Anesthetic carpules require especial consideration, since it is known 
that prolonged submergence will permit infusion by chemical disinfectants. 
Immersion for 15 to 30 minutes is considered acceptable. Only 70 percent 
ethyl alcohol may be used. Dental Division, BUMED 



Personnel and Professional Notes 

Preventive Dentistry Program Successful at NavHosp Pensacola . CDR H. S. 
Samuels, DC USN, Chief of Dental Service, U.S. Naval Hospital, Pensacola, 
Fla. , has announced the details of a successful preventive dentistry program. 
Launched in August 1963, under the direction of LCDR M.S. Burch, DC USN, 
the program includes bedside oral hygiene care for ward patients. 

Current SnFo prophylaxis techniques are supplemented by regularly 
scheduled slide-lecture demonstrations throughout the hospital by a dental 
officer/technician team. A battery-powered toothbrush has been made 
available to ward corpsmen, who provide normal oral hygiene care for debil- 
itated patients. 

Personnel are continuously reminded of proper oral hygiene by regular 
dissemination of information through the plan-of-the-day, pertinent hand-outs, 
etc. The common denominator of a successful preventive dentistry program 
seems to be a constant, vigorous approach. 

Dental Facility Established in Alaska for Personnel in Remote Areas . Facili- 
ties have been provided for dental treatment aboard the U.S. Naval Communi- 
cations Station, Clam Lagoon, Alaska. In the past, Navy personnel spent many 
man-hours traveling to keep dental appointments at U. S. Naval Station, Adak, 
Alaska. Through the efforts of many people, including CAPT R. B. Haynes, 
DC USN, Dental Officer of the Naval Station, Adak, this new dental facility was 
established nine months to the day following the initial request. 

New Dental Teaching Films. A new series of educational films has been de- 
veloped by the U.S. Naval Dental School. These are black and white sound 
films transferred from videotapes used in the Dental School's teaching program. 
The films cover subjects of current interest in dental practice and are well 



U.S. Navy Medical News Letter, Vol. 44, No. 1 27 

suited for use by study and discussion groups. The following films, which 
comprise the initial series, are available on loan to dental activities of the 
military services, to dental societies, and to teaching institutions. 

1800-59 Prevention of Dental Caries --16 mm. ; black & white; sound; 
15 minutes. Reviews the factors responsible for dental caries and illustrates 
characteristics of the lesion in its early stages. Film includes recommenda- 
tions for practical application of preventive techniques. 

1800-60 How Partial Dentures Affect Abutment Teeth --16 mm. ; black 
& white; sound; 15 minutes. Illustrates how forces are exerted on abutment 
teeth by partial dentures and shows a suggested denture designthat will control 
these forces. 

1800-61 Wounds of the Face --16 mm. ; black & white; sound; 15 minutes. 
Discusses early diagnosis and illustrates the basic techniques in treatment of 
oral and facial wounds. 

1800-62 Modern Cavity Preparation - -16 mm. ; black & white; sound; 15 
minutes. Demonstrates the changes in cavity preparation incident to the advent 
of the air-turbine. The concepts included are the rubber dam, washed-field 
technique, instrumentation, and newly designed burs. 

1800-63 Correct Pontic Design --16 mm. ; black & white; sound; 15 min- 
utes. Reviews and illustrates the requirements and design of pontics for 
successful fixed partial dentures. 

Requests for videotape transfer films should be directed to: Command- 
ing Officer (Code E3), U.S. Naval Dental School, National Naval Medical 
Center, Bethesda, Maryland 20014. 

Dental Research Officer Participates in Oral Science Seminar . CAPT Fred 
L. Losee, DC USN, presented some of the aspects of the Caries Immune 
Program being conducted at the Naval Training Center, Great Lakes, before 
the Oral Science Seminar on 21 May 1964. The seminar, sponsored by the 
Department of Nutrition and Food Science, Massachusetts Institute of Tech- 
nology, Boston, Massachusetts, was attended by dental students of Harvard 
and Tufts Universities, and the staff of the Department of Nutrition and Food 
Science of MIT and their post-doctorate trainees. 

CAPT Losee is Dental Research Officer, Dental Research Facility, 
USNTC, Great Lakes, Illinois. 

Master Chief Bloom Transferred to Fleet Reserve . Master Chief Dental 
Technician Ralph Bloom transferred to the Fleet Reserve on 28 May 1964. 
He has served the past five years at the Bureau of Medicine and Surgery in 
the Dental Technician Section of the Personnel Branch of the Dental Division. 
His successor at the Bureau is Master Chief Dental Technician Vernon 
R. Burke who, prior to this assignment, served as Personnel Records Super- 
visor for the Naval Dental School, Bethesda, Maryland. 



28 U. S. Navy Medical News Letter, Vol. 44, No. 1 




PREVENTIVE MEDICINE 



Tuberculosis Control Program 

Tuberculosis becomes epidemic most often when an active spreader of viru- 
lent tuberculosis organisms is in confined quarters such as a ship. Yet our 
most effective tool in following contacts of an active case is blunted by sheer 
lack of concern or awareness on the part of medical officers and medical 
department representatives. 

In a recent spot check on Health Records in the Southeastern United 
States, the Inspector General (Medical) found only 44% of health records 
reviewed had the tuberculin status of the individual recorded. In recent years 
every Navy and Marine Corps recruit has been skin tested in boot camp (since 
1956 in the case of Navy recruits) and annual health record verifications should 
have caught the records of the more senior men not tested in boot camp. 

Surveys by numerous investigators and United States Public Health 
Service studies have clearly demonstrated the value of skin test studies of all 
known contacts of cases of active tuberculosis. The economy of the method 
and yield of new cases make skin testing an effective tool for tuberculosis 
control in small closely associated groups such as naval units. 

Multiple puncture tests such as the Tine test for tuberculin skin testing 
are not recommended. The Mantoux technique (article 15-91, MMD) utilizing 
purified protein derivative of tuberculin is necessary to insure comparability 
of results with tests in previous years and in the serial tests prescribed in 
the basic instruction on contact investigation. 

A recent survey of tuberculosis cases reported to BUMED during the 
first six months of 1963 revealed a number of discrepancies in the execution 
of BUMED INST 6224. IB. Particular neglect has occurred in regard to par- 
agraph 4c{4) which requires summary reports of the status of the control in- 
vestigation. The following is typical of current observance: 88 cases of pul- 
monary tuberculosis were reported; only 57 contact investigations had been 
done; only 34 contact studies submitted summary reports. 

Present tuberculosis control instructions are undergoing revision with 
the primary intent of decreasing paper work in the field and obtaining more 
meaningful reports in BUMED. The summary reports mentioned above will 
still be required — such a summary should be less than a page in length and 
show the number of persons studied, the number of persons transferred since 
initial testing, the number of negatives, the number of positives, the number 
of converters (on whom Isoniazid prophylaxis reports are required) and the 



U. S. Navy Medical News Letter, Vol. 44, No. 1 29 

name of the index case. 

Medical department representatives and medical officers are reminded 

that the U.S. Navy Preventive Medicine Unit No. 2 in Norfolk, Virginia, 
No. 5 in San Diego, California, No. 6 in Pearl Harbor, Hawaii and No. 7 
in Naples, Italy are available with advice and materials for testing. 

Tuberculosis Control Sec, PrevMed Division, BuMed 

****** 
Military Entomology Information Service 

The Military Entomology Information Service, a scientific communication 
service of the Armed Forces Pest Control Board, located at the Forest Glen 
Section, Walter Reed Army Medical Center, has been in operation for over 
a year. It is manned by Medical Service Corps entomologists from the Army, 
Navy and Air Force. 

This specialized information center, quite similar in concept to centers 
operated for other scientific disciplines, has the primary objective of render- 
ing communication service to the individual scientist. More specifically, the 
service has the following objectives: 

a. To assemble available information on arthropods and other pests 
which may affect military operations in selected geographical areas, with 
particular emphasis on disease vectors. 

b. To organize information relating to military entomology and to 
provide for its storage and retrieval. 

c. Respond to requests for specific information from military en- 
tomologists, technical services, preventive medicine laboratories and units, 
epidemiological flights and laboratories, disease vector control centers, 
Armed Forces research activities, and related government offices. The 
system is not designed to readily respond to general demands. 

d. Periodically distribute new accessions, or bibliographic citations 
of selected accessions, to military entomologists whose specific fields of in- 
terest are made known to the Armed Forces Pest Control Board. 

The system adopted by the service employs an optical coincidence, 
inverted file system for input, storage, and retrieval, coordinated with an 
electronic semi-automatic writing -coding unit and an electrostatic reproduc- 
tion center. These components comprise what is popularly recognized as an 
"Integrated Data Processing System". 

The output of the Service is entirely scientific no administrative 

recommendations or procedural policies are intended in any response. The 
Service responds directly to the requestor, or to the chain of command 
through which the request was received. 

Requests for information should be addressedto the Officer-in-Charge, 
Military Entomology Information System, Armed Forces Pest Control Board, 
Forest Glen Section, Walter Reed Army Medical Center, Washington, D.C. 20012. 



30 U. S. Navy Medical News Letter, Vol. 44, No. 1 



^Rttofo 




DID YOU KNOW: 

That in 1963, 3,933 laboratory confirmed cases of rabies were reported 
in the United States ? 

This is more than 200 cases over the number reported in 1962, or 3,727. 
This difference is due to a general increase in bat rabies cases and to an 
epidemic of rabies in raccoons in the Southeast. Other shifts in the epidem- 
iologic pattern of rabies in the United States include extension of the already 
large epidemic of skunk rabies in the central part of the country, the emer- 
gence of epidemic fox rabies in New England, and an increased concentration 
of dog rabies cases along the United States -Mexico border. As in the previous 
two years, rabies cases in wildlife have increased while the number in domestic 
animals remains constant. (1) 



That Ethiopia officially declared itself free of yellow fever on 10 Mar 
1964? 

This is the first time Ethiopia has declared itself free of this disease 
since the International Sanitary Regulations of the World Health Organization 
were adopted by the Fourth World Health Assembly in 1951. (2) 



That U. S. Patent No. 3, 120, 796 describes a method and apparatus for 
protecting the ventilation systems of vessels? 

The ventilating systems of vessels are protected against airborne 
contamination damage resulting from atomic, bacteriological and chemical 
attacks. (3) 



That the " Current Pest Control Recommendations " were revised in 
December 1963? 

The Technical Information Memorandum No. 6 is distributed to provide 
information for the professional personnel of the military services who are 
responsible for direction, supervision or guidance of pest control operations. 
(4) 



That during 1963, 7 cases of tetanus with 5 deaths were reported from 
the State of Virginia? 

Ages were 6 days, 5, 11, 50, 51, 83 and 90 years each. The 6-day old 
infant, born at home of an unimmunized mother, presented with an umbilical 
infection and clinical tetanus, died shortly after hospital admission. In the 
other 6 cases, the wounds were so minor that medical attention was not sought. 



U. S. Navy Medical News Letter, Vol. 44, No. 1 31 

Tetanus probably would not have resulted if tetanus toxoid immuniza- 
tion had been a past experience. As of 11 April 1964, 2 cases of tetanus have 
occurred. A 48 -year old woman presented the complaint that a splinter had 
stuck in her foot while walking barefoot in her home. During this visit a 
splinter was not demonstrated; however, an injection of tetanus antitoxin was 
given. Five days later, cellulitis was apparent, a splinter was recovered and 
antibiotics were started. Subsequently, difficulty in swallowing and muscle 
stiffness were noted. She did not respond to therapy, including tetanus anti- 
toxin and expired 9 days after the splinter had been removed. The second 
case occurred in a 48-year old carpenter who stuck a nail superficially in his 
hand one week prior to onset of symptoms. The wound was not treated and 
apparently healed. He was seen in the hospital emergency room with "stiffness 
of neck, locked jaws; the head was drawn back and the abdomen was rigid. " 
On admittance to the hospital, tetanus antitoxin was given, but he expired the 
following day. {5) 

Bibliography: 

1. CDC Veterinary Publ. Hlth. Notes, April 1964. 

2. USDHEW PHS WKLY Morbidity & Mortality Rpt, Vol 13{14): 124, 10 April 
1964. 

3. National Academy of Science, NRC Prevention of Deterioration Center 
(PDC) Newsletter, Vol VII (3): 4, April 1964. 

4. National Academy of Science, NRC Prevention of Deterioration Center 
(PDC) Newsletter, Vol VII (3): 4, April 1964. 

5. Commonwealth of Virginia Dept of Health, Bureau of Epidemiology, Mor- 
bidity Report, 11 April 1964. 

****** 
New Test for Diagnosing Sporotrichosis 
USDHEW PHS CDC, Vet Pub Hlth Notes, May 1964. 

Dr. William Kaplan of the Mycology and Parasitology Section, Laboratory 
Branch, Communicable Disease Center, working in cooperation with Dr. An- 
tonio Gonzalez Ochoa of the Mexican National Institute of Tropical Diseases, 
has developed a new, rapid method if diagnosing sporotrichosis through the 
use of the fluorescent antibody technique. The accuracy of this test compares 
favorably with that of other tests and can be completed in 2 hours. 

A study was conducted to compare the efficacy of the fluorescent anti- 
body procedure with that of conventional culture procedures. Using the FA 
technique, Sporotrichum schenchii was demonstrated in 89 percent of patients 
found positive with the culture test, including 1 case found negative by the cul- 
ture test. This FA identification was confirmed later by skin test. 



32 U. S. Navy Medical News Letter, Vol. 44, No. 1 

Isolation of the fungus by culture is considered the best procedure, but 
requires a week or more for results. A skin test requires 48 hours, and the 
results are essentially presumptive in nature. 



Ultraviolet Closed Circuit TV Microsco 



EI 



The application of ultraviolet -sensitive TV camera tubes to medical and bio- 
logical microscopy problems has been attempted several times during the past 
decade. Several years ago, a short note in Nature (192, p. 1060, Dec. 16, 1961) 
discussed some of the work being done in the United Kingdom on the use of 
ultraviolet light for studies of live cells. In that note, preliminary data were 
given on an experimental ultraviolet-sensitive vidicon being developed by EMI 
Ltd. Due to the potential applications of this tube, which has now been placed 
on the market, some of its characteristics will be summarized here. 

The arsenic triselenide target layer, deposited on the quartz faceplate, 
gives a sensitivity of at least 0. lua/u wcm -2 in the ultraviolet region down to 
2500 A. The peak sensitivity is 0. 2 ua/uwcm" 2 at 4000 K and less than 0. 01 
ua/uwcm~ 2 for wave lengths greater than 6000 X. The unity gamma over 
most of the useful range of operation allows the wave-form to be used to give 
a direct measure of absorption of the observed object, A separate mesh 
electrode results in excellent overall resolution over a I cm 2 scanned area. 

This new microscope should be of great interest to cytologists. Pro- 
fessor R. Barer (Univ. of Sheffield) has pointed out in the above reference 
that magnifications of 3000 times could be obtained, focusing is not a problem, 
relatively thick specimens can be investigated and a large number of fields 
may be scanned in a rather short time. Probably one of the most interesting 
applications will be quantitative cytochemical studies using the refractive 
index and absorption of living cells. The possibilities for rapid microspec- 
trophotometry of living matter should open new vistas for the cell physiologist. 
"Optical dissection" can possibly give us better knowledge of fine structure 
in organisms not distorted by harsh chemicals or physical stresses. 

G. H. Keitel and J. R. Kingston 



-A. %L> JU 

-JC ,-p ^ 



Jimson Weed Poisoning - Tennessee 

USPHS DHEW Morb & Mort Wkly Rpt. , 13(15): 125-12 7, 10 Apr 1964. 

An unusual outbreak of stramonium food poisoning related to jimson weed 
consumption was reported from Hawkins County, Tennessee. Five persons in 
all became ill between 5 minutes and 5 hours after consuming tomatoes which 
contained the alkaloid. 



U. S. Navy Medical News Letter, Vol. 44, No. 1 33 

Five minutes after eating, 2 adults became acutely ill at the luncheon 
table with visual hallucinations, disorientation, generalized weakness, blurred 
vision, pronounced thrist, vertigo and nausea. They were hospitalized im- 
mediately. On physical examination, both had dilated, sluggishly reactive 
pupils. Within 5 hours of this meal, the other 3 sharing it had become ill with 
similar, but milder, symptoms. 

The meal had consisted of fresh, sliced tomatoes, split pea soup, spa- 
ghetti, sweet milk, and cornbread. Both the split pea soup and the spaghetti 
had been served 2 days earlier; they had been reheated for this meal. 

One individual had consumed 3-1/2 slices of tomato and 4 others had 
eaten 1 slice each of fresh tomato. Commercially canned tomatoes were used 
in the spaghetti. 

The Division of Preventable Diseases, Tennessee State Health De- 
partment, noted that the tomatoes served at the meal had been "grown with 
jimson weed. " Immediate examination of the State Toxicology files yieldeda 
description of jimson weed poisoning, the toxic principal being the alkaloids 
stramonium, hyoscyamine, scopolamine, and atropine. Certain that jimson 
weed explained their symptoms, this information was telephoned immediately 
to their physicians. 

The tomato consumed at the meal was obtained from a tomato plant 
grafted to the root of a jimson weed ( Datura stramonium ). This had been done 
in an attempt to produce a larger tomato, more resistant to cold. 

Case Number 1 had become familiar with this grafting procedure through 
a neighbor (not a victim). This neighbor had attempted tomato grafting with 
several plants for 5 years, but had been successful only with the jimson weed. 
He had only occasionally tasted tomatoes from these plants. He never experi- 
enced ill effects. 

The tomato consumed at the above meal was the first to be eaten from 
Case Number l's plants. Following this incident, it was learned that Case 
Number l's grafts were made with an above-ground secondary branch of the 
jimson weed, whereas the neighbor had always grafted the stalks to the roots 
below ground. 

Tennessee health authorities conclude that this modification in technique 
may have accounted for the toxicity of Case Number l's tomatoes. 

One whole tomato was retrieved from Case Number l's home and for- 
warded to the Tennessee Industrial Hygiene Laboratory. This was produced 
by the same grafting technique but did not come from the same plant that 
yielded the tomato consumed at the above meal. Three tomatoes were also 
obtained from the neighbor's home (grown by grafts made to the root stalks). 

Case Number l's tomato yielded 4. 2 milligrams of stramonium alkaloids 
per 100 grams of tomato; the neighbor's tomatoes yielded 1. 9 milligrams per 
100 grams. 

The tested tomato would contain about 1.0 milligrams of total alkaloid 
per slice, according to calculations from the laboratory results; since the 
ingested tomato was not analyzed, direct comparison of dosage and symptom- 



34 U. S. Navy Medical News Letter, Vol. 44, No. 1 

atology was not possible. 

Numerous case reports of jimson weed poisoning have appeared in the 
medical literature; yet there is no available report of the stramonium alkaloids 
being transferred to a second plant grafted to the host jimson weed. 

The jimson weed ( Datura stramonium), also known as thorn apple, 
Jamestown weed, stink weed, devil's apple, and apple of Peru, is a species 
of the Solanacea family to which the red pepper, tobacco, "tomato, and bella- 
donna plants belong. The plant is prevalent in this country and in all temper- 
ate and tropical zones, flowering in late spring and with the fruit ripening in 
early fall. All parts of the plant are poisonous, especially the seeds. It is a 
malodorous, tall, branched plant which attains a height of 3 to 6 feet with trum- 
pet-shaped flowers and spinous capsule whiph contains numerous black-brown 
seeds. •*• 

The plant grows wild around barn yards, manure piles, and road slides, 
and is readily available to the sampling of inquisitive children. Mitchell 
reported that between 1950 and 1955, jimson weed intoxication accounted for 
4% of pediatric patients admitted to the University of Virginia hospital because 
of the accidental ingestion of toxic substances. In this hospital this was approx- 
imately the same frequency as intoxications due to lead, alcohol, barbiturates, 
and insecticides. Most cases result from the plant's use in jimson weed tea, 
reportedto be an effective treatment for asthma and other respiratory ailments. 



1. Jennings, R. E. : Stramonium poisoning: review of the literature and re- 
port of two cases. J Pediatrics 6:657, 1935. 

2. Mitchell, J. E. and Mitchell, F. N. : Jimson weed { Datura stramonium) 
poisoning in children. J Pediatrics 47: 227, 1955. 

3. Goodman, JL. S. and Gilman, A. : The pharmacological basis of thera- 
peutics, The Macmillan Co. 2nd ed. N. Y. 1958, pages 552-553. 

*T* *** *)* *V *P *F 

Medical Practitioners and Preventive Medicine 

WHO Chronicle 18(5): 177-179, May 1964. 

"The unique characteristic of preventive medicine is its relevance to 
every specialty of medical practice and to the work of the medical 
practitioner. " 

"The prevention of disease, however, requires more than skills and 
techniques for it is the bed-rock of medicine itself. "* 

It might be thought that the preventive aspects of medicine are so obvious that 
no effort is needed to convince medical practitioners of their importance. In 
the developed countries the major health problems nowadays include the car- 
diovascular diseases, cancer, mental disorders, and the special problems of 



U. S. Navy Medical News Letter, Vol. 44, No. 1 35 

urbanization such as accidents and drug addiction, as well, perhaps, as ju- 
venile delinquency. Most, if not all, of these conditions carry with them im- 
portant social and economic implications; and, with the increasing cost of 
treatment, no country can affordto rely only on attempts to cure them. In the 
developing countries, too — and this is a pointthatis not so readily appreciated 
—the same problems will shortly have to be faced, for what sets their dis- 
eases apart from those of developed countries is less a difference of pattern 
than a difference of time. 

In the developing countries the problems of health and disease are so 
great that medical practitioners must necessarily interest themselves to some 
extent in prevention. The acute infections; contamination of water, food, and 
soil by human excreta, with resulting infection and infestation; insect-borne 
and other vector -borne diseases; poor housing; poverty; illiteracy; malnutri- 
tion; and deeply rooted customs, habits, and beliefs: these compel physicians 
to play a multiple role, treating disease, acting perhaps as health officers and 
administrators, perhaps undertaking research into the health conditions of the 
area where they practice. 

A WHO Expert Committee on Professional and Technical Education of 
Medical and Auxiliary Personnel states in its report 1 just issued, on the 
promotion of medical practitioners' interest in preventive medicine: "It is im- 
perative that the medical profession should accept the preventive idea whole- 
heartedly and that this should become part of its basic way of thought. Already 
the amount of preventive work undertaken is considerable. We are, in fact, 
dealing with a new and advancing frontier, " 

If the medical practitioner in the developing country is in the position 
that he can scarcely avoid having to deal with the prevention of disease, his 
professional colleagues in the developed countries may never give prevention 
morethana pas sing thought. Receiving their medical education in universities 
or medical schools where the whole emphasis is on the curative aspects 
of disease, they go into hospitals for postgraduate training and then into prac- 
tice where they spend their entire time in treating sick patients. The amount 
of time in the medical curriculum devoted to public health and prevention is 
small in comparison with that devoted to internal medicine or surgery; the 
status of the subject is correspondingly low; andsincethe greatest part of the 
clinical years is spent in hospitals where the preventive aspects of disease 
play a very small part medical students not unnaturally tend as a body to view 
medicine as preponderantly curative. Yet there is no doubt that by the use of 
preventive techniques the medical practitioner can serve his patients more 
effectively, enlarge the scope and interest of his practice, contribute apprec- 
iably to community health, and complement the work of the specialized hospital 
and public health services. 

Undergraduate Teaching of Preventive Medicine. The Expert Committee 



1. World Hlth Org. Techn Rep. Ser. , 1964, Z69. 



36 U. S. Navy Medical News Letter, Vol. 44, No. 1 

suggests three main ways of improving the teaching of preventive medicine to 
medical students: first, a substantial amount of preventive medicine should 
be included in the undergraduate curriculum for all departments; secondly, its 
teaching should be organized largely through professorial departments of pre- 
ventive medicine; and thirdly, special attention should be paid to the status of 
the subject, which is reflected in such things as the quality and number of the 
teaching staff, salaries, equipment, research facilities, the amount of teach- 
ing time devoted to preventive medicine, and the importance assigned to it in 
examinations . 

The teachers of all the pre-clinical and clinical subjects must be able 
to deal with the preventive aspects of their particular specialties; in addition, 
it is essential to have a professorial department of preventive medicine in 
each medical school, not only to promote the status of the subject but also to 
link up the other departments in the school. The department could also offer 
statistical, epidemiological, and other services, and act as a bridge between 
the teaching hospital and the community. 

As preventive medicine is not a separate subject but an aspect of each 
of the other medical subjects, it should be taught at all stages of the curricu- 
lum. It is particularly important to ensure that the student will not lose 
interest in preventive medicine during the clinical years. 

The emphasis given to the different branches of preventive medicine 
in the curriculum will of course vary according to the needs. Developing 
countries will be preoccupied with the mass diseases, hygiene, environmental 
control, and problems of nutrition. With the growth of industrialization there 
will be more emphasis on the organization and administration of health and 
welfare services, while in the more developed countries prominence will be 
given to the diseases of urban and industrial life and the health problems of 
aging populations. 

j- The traditional public health subjects offer, of course, the best oppor- 
tunities for teaching preventive medicine. To these should be added: the 
epidemiology of diseases, injuries and disabilities; medical statistics; medi- 
cal aspects of sociology, social psychology, and anthropology; elementary 
genetics; economic aspects of medical care; and the organization of health 
and welfare services. In addition, certain subjects may require special 
emphasis: these include industrial medicine, housing, the control of radiation 
hazards, drug addiction, problems of adolescence and delinquency, and the 
use of health indices. The essentials of communication techniques should 
also be taught, with particular reference to health education. 

The teaching and learning of preventive medicine should be an active 
process, the seminar being preferable to the lecture as a teaching method. 
Ideally, the subject should be taught in the community itself. Work in the 
homes of patients should serve to counteract to some extent the traditional 
emphasis on the hospital "case". Demonstrations of the different ways of 
organizing community health services are of particular importance. The 
student shouldhave the opportunity of working in a general practice or health 



U.S. Navy Medical News Letter, Vol. 44, No. I 37 

center with practitioners familiar with preventive techniques. Textbooks 
should give the prevention of disease an equal place with causation, diagnosis, 
prognosis, treatment, and rehabilitation, and there shouldbe special textbooks 
on preventive medicine. 

Interesting the Practitioner in Preventive Work. If the practice of 
preventive medicine is to be encouraged, the general practitioner must have 
the wholehearted support of the medical schools, the medical associations, 
and the health authorities. The community should provide, as far as its re- 
sources permit, for the postgraduate education of the general practitioner in 
this field. Such education should be carried out by means of short courses 
and demonstrations— —for example, on presymptomatic screening for chronic 
diseases, genetic counselling, and the rehabilitation of the disabled — relating 
preventive ideas to the day-to-day practice of medicine. 

Above all, inertia and resistance on the part of the practitioner must 
be overcome. He must be convinced that it is as useful and intellectually 
satisfying to prevent disease and disability from occurring as to treat and 
correct it when it exists. Ways of interesting him in preventive medicine in- 
clude: assigning him an active role in immunization and other campaigns, 
arranging exchanges and visits to areas where effective preventive work is 
being carried out, providing him with manuals and guides, encouraging him 
to take part in teaching and research, and promoting a public demand for 
more preventive services. 

$$$$$$ 

Measles 

USDHEW PHS Wkly Morb & Mort Rpt, 13(12): 93-101, 27 Mar 1964. 

A nationwide epidemic of Rubella (German measles) has been in progress 
throughout the country. A rise in reported cases was first noted late in the 
Fall 1963, in the northeast United States. The outbreak has spread rapidly 
to the south and west. With the exception of Minnesota, all States have noted 
a marked rise in reported Rubella cases. Increases were observed in Janu- 
ary 1964, in the Mid-Atlantic and East North Central areas, and in February 
1964, in the South Atlantic, East South Central, West South Central, andMoun- 
tain areas. Laboratory identification of the etiologic agent in specimens from 
typical cases has been accomplished in New York City, Philadelphia, and Cleve- 
land; in other areas, the diagnosis has been made on the basis of clinical char- 
acteristics of the illness. 

Several States optionally report Rubella cases on an annual basis to 
the Communicable Disease Center, Public Health Service, U. S. Department 
of Health, Education and Welfare, Atlanta, Georgia. The similarity of the 
patterns observed in the various geographic areas to that seen for the nation 
as a whole is of interest. The Pacific States (Washington and Oregon) demon- 



38 U. S. Navy Medical News Letter, Vol. 44, No. 1 

strate a curve similar in shape to that observed in other areas, but with an 
apparent one -year shift to the right. 

The clinical characteristics of the disease now occurring have varied 
within the spectrum of signs and symptoms classically described for Rubella. 
The rash most frequently described is maculopapular, beginning first on the 
face and neck, with rapid progression to trunk, arms, hands, legs, and feet. 
Cervical, occipital, and postauricular lymphadenopathy has been a prominent 
feature in reported cases; while most patients have experienced mild fever, 
the maximum level has not been impressive. In some areas, arthralgia re- 
sembling that of rheumatoid arthritis has been noted. The disease lasts 3-7 
days and has been symptomatically mild. Most of the victims are children of 
school age, but cases have also occurred among preschool children as well 
as adults. Prophylaxis with gamma globulin has been used widely in the first 
trimester of pregnancy. 




RESERVE ^MBST SECTION 



American Psychological Association 

The Annual Meeting of the American Psychological Association will be heldat 
Los Angeles, California during the period 4-9 September 1964. A Military 
Symposium in conjunction with the meeting will be held on 4, 5, 6, 7, 8, and 
9 September. Each session will be at least two hours in duration. 

By authority of the Chief of Naval Personnel, one retirement point may 
be credited to eligible Naval Reserve Medical Service Corps (Psychology) of- 
ficers in attendance. Officers are requestedto register with the Commandant's 
Representative in order that attendance may be recorded and reported. 



American Board Certifications 

This Bureau has been notified by the American Board of Internal Medicine that 
the following Reserve Officers have been certified: 

LTChester Alan Alper MC, USNR 614526/2105 

LT Axel W. Anderson, III, MC, USNR 618840/2105 

LCDR Charles H. Banov, MC, USNR 582224/2105 

LT Thomas J. Bellezza, MC, USNR 565542/2105 

LCDR Meriwether C. Blaydes MC, USNR 611336/2105 

LCDR Irwin M. Bogarad MC, USNR 610199/2105 



U. S. Navy Medical News Letter, Vol. 44, No. 1 



39 



LT Donald Louis Bucy MC, USNR 

LCDR Wallace F. Buttrick MC, USNR 

LCDR James F. Casey MC, USNR 

LTJG Solon L. Coleman III MC, USNR 

LCDR Norris R. Dougherty MC, USNR 

LT Barry Jay Fenton MC, USNR 

LT William S. Fletcher MC, USNR 

LCDR "J" Clark Ford MC, USNR 

LT Edwin G. Graves, Jr. , MC, USNR 

LT Matthew L. Greenberg MC, USNR 

LCDR Joseph H. Hardison, Jr. , MC, USNR 

LCDR John Burkett Hill, MC, USNR 

LCDR William D. Hoadley MC, USNR 

LCDR Lee Hoffman MC, USNR 

LT Edwin H. Hopton MC, USNR 

LCDR Paul K. Jones MC, USNR 

LT James F. Leary MC, USNR 

LCDR John Milton Lewis MC, USNR 

LCDR Lonnie Clifford McKee Jr. , MC, USNR 

LCDR Jess P. Miller MC, USNR 

LT Peter W. Morris MC, USNR 

LT Marvous E. Mostellar MC, USNR 

LCDR Paul M. Nonkin MC, USNR 

LCDR Maurice A. Pearl MC, USNR 

LT Walter Puckett III MC, USNR 



625524/2105 
483442/2105 
613211/2105 
554423/2105 
575911/2105 
623968/2105 
541750/2105 
606087/2105 
611250/2105 
620309/2105 
616837/2105 
623142/2105 
614489/2105 
618111/2105 
617187/2105 
606196/2105 
594941/2105 
607022/2105 
625410/2105 
623519/2105 
617941/2105 
605660/2105 
589101/2105 
613362/2105 
613076/2105 



How Much Do You Know About The Selected 
Reserve? - Continued 



The Commander, Naval Reserve Training Command, with headquarters in 
Omaha, Nebr. , oversees the training of more than 94,000 Selected Reser- 
vists, working through the naval district commandants. The Chief of Naval 
Air Reserve Training, headquartered at NAS Glenview, 111. , supervises the 
training of Selected Air Reservists. 

There are more than 300 Naval Reserve Training Centers and Train- 
ing Facilities and 140 Electronics Facilities established in major population 
centers. Air Reserve squadrons are based at 18 Naval Air Stations and 
NARTUs throughout the country. 

Some training centers are located near available pier space where 
training ships and submarines can be moored, thereby making dockside train- 
ing readily available. There are 35 Naval Reserve Training Ships including 
patrol craft and 23 immobilized submarines, in addition to the 40 destroyer- 
type ships and 12 mine-craft. The patrol craft are, for the most part, located 
in the Great Lakes, 

The Naval Reserve's mobilization needs must be measured in terms of 



40 



U. S. Navy Medical News Letter, Vol. 44, No. 1 



ships, aircraft and trained and qualified personnel. The present strength in 
drill pay status in the Selected Reserve, both Surface and Air is above 127, 000; 
it is steadily increasing. The authorized strength is 126, 000 in drill pay status. 

Just how effective is our Selected Reserve? What is being done to 
improve it? Here are a few quotations, taken from a speech given a few 
months ago by RADM F. J. Becton, USN, Commander Naval Reserve Training 
Command: "Just as we need a powerful Navy to protect our sea lanes, so also 
do we need a strong Naval Reserve, trained and ready to reinforce it in an 
emergency. Our ASW ships will augment Hunter -Killer groups in the event of 
mobilization. During the past year, we have made significant progress in a 
number of areas. . . . "In August 1962, our 40 DDs and DEs of our ASW Com- 
ponent returned following the Berlin recall and resumed their former status as 
Reserve training ships. At the end of August of that year, we had in the Re- 
serve Crews less than 1000 enlisted men. Since that date, this figure has 
risen to almost 4000. We have made steady progress in attaining our goal of 
full on-board strength. 

"ASW conferences held in San Diego and Norfolk have been highly suc- 
cessful in pointing up problem areas and offering realistic solutions. Similar 
conferences for Mine Warfare and Ship Activation, Maintenance and Repair 
personnel were held in Norfolk and Long Beach. Through these conferences, 
where we discuss mutual problems, we are promoting much greater interest 
in the various Reserve programs involving our NRT ships. 

(To be continued) 

****** 



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